Suprasellar Meningioma Research Articles

Pituitary function after endonasal surgery for nonadenomatous parasellar tumors: Rathke's cleft cysts, craniopharyngiomas, and meningiomas

Background Transsphenoidal surgery for parasellar nonadenomatous lesions has the possibility to either improve or worsen pituitary hormonal function. Herein we present the rates and risk factors of new hormonal failure and recovery in patients undergoing surgery for either an RCC, craniopharyngioma, or tuberculum sella meningioma. Methods All consecutive patients treated over an 8-year period by endonasal surgery for an RCC, craniopharyngioma, or tuberculum sella meningioma were analyzed. Patients treated with prior sellar radiotherapy were excluded. Preoperative and postoperative pituitary hormonal status was determined. Patient characteristics, tumor size, intraoperative and postoperative events, and extent of tumor resection were correlated with new or resolved hypopituitarism. Results In total, 50 patients with an RCC, 18 with a craniopharyngioma and 13 with tuberculum sellae meningioma, were analyzed. New anterior pituitary failure and permanent DI occurred as follows: in RCCs, 6% and 2%; in craniopharyngiomas, 31% and 39%; and in meningiomas, 9% and 0%. Overall, improved hormonal function occurred in 57% of patients with an RCC including recovery of one or more anterior axes in 9 (41%) of 22 patients and resolution of hyperprolactinemia in 12 (67%) of 18 patients; no patients with a craniopharyngioma or meningioma had resolution of hypopituitarism. Younger age was predictive of hormonal recovery in patients with an RCC ( P = .026). Conclusions New hypopituitarism after transsphenoidal surgery occurs in approximately one third of patients with a craniopharyngioma and in less than 10% of patients with an RCC or suprasellar meningioma. Hormonal function improves in the majority of patients undergoing drainage of an RCC but is unlikely to occur after removal of a craniopharyngioma or suprasellar meningioma.

Suprasellar meningioma. A disease still frequently diagnosed too late

Suprasellar meningioma continues to be diagnosed very late after the onset of first eye symptoms. This study was aimed at demonstrating the effect of delay on the long-term visual loss. In the course of a retrospective study all 53 consecutive patients operated on for suprasellar meningioma from 1982 to 1991 were contacted (47 women, 6 men; average age 49.5 years) 46 of the 49 surviving consented to the follow-up investigation. The extent of preoperative visual loss, tumour size, presence of optic nerve atrophy and duration of visual loss, data that provide an indirect measure of how soon the correct diagnosis was made, were analysed with regard to their effect on long-term ophthalmological results. The mean period elapsing from onset of first visual symptoms to the definitive diagnosis of suprasellar meningioma was 22.3 months. The data showed that the long-term results were the worse the later the diagnosis was made. The commonly very late diagnosis of suprasellar meningioma as cause of visual loss is an international problem and is presumably due to the low incidence of the tumour (1-2 cases per 1 mill. population per year). If long-term results are to be improved, primary care doctors must be made aware of the differential diagnosis of visual loss caused by pressure from a tumour.

Exclusive Endoscopic Removal of a Planum Sphenoidale Meningioma: A Case Report

Midline suprasellar meningiomas have traditionally been removed through transcranial approaches. Endoscopic endonasal approaches have already been described for the removal of tuberculum sellae meningiomas (Cook), but their exclusive use for planum sphenoidale meningiomas has never been reported. A case report of a planum sphenoidale meningioma removed through a transnasal endoscopic approach is presented: the goal of this technique is tumor control with minimal morbidity. The anterior skull base defect has been reconstructed with a pedicled mucosa flap from nasal septum (Hadad-Bassagasteguy flap). The postoperative course was uneventful, and no sign of recurrence was noticed at the MRI control performed after 3 months.

Postoperative improvement in visual function in patients with tuberculum sellae meningiomas: results of the extended transsphenoidal and transcranial approaches

Recently, extended transsphenoidal surgery (ETSS) has become an alternative to transcranial surgery (TCS) for suprasellar meningiomas, although the relative benefits of ETSS have yet to be established. To evaluate the effectiveness of ETSS, the authors analyzed surgical outcomes of TCS and ETSS. During a 12-year period, 28 patients with meningiomas arising from the tuberculum sellae underwent tumor removal at Kinki University Hospital. The first 12 patients underwent TCS, and the remaining 16 underwent ETSS. In the TCS group, the optic canal on the approach side was unroofed in all cases. In the ETSS group bilateral optic canals were opened, and the dural and bone defects of the skull base were repaired using abdominal fascia and hydroxyapatite cement. In half of the cases, lumbar drainage of cerebrospinal fluid (CSF) was also performed. In a retrospective analysis of this consecutive series of patients, improvement in visual acuity and intraoperative blood loss were significantly better in the ETSS group (p = 0.010 and p = 0.011, respectively), whereas improvement in visual field defects, operative times, and the tumor removal rate were not significantly different between the two groups. Nonvisual surgical complications such as CSF leakage (one patient) and infarction of a perforating artery (three patients) were observed in the TCS group. In the ETSS group, CSF leakage (two patients), anosmia (two patients), and infarction of a perforating artery (two patients) were observed. Given the encouraging results in improvement in visual acuity, ETSS may be acceptable for the treatment of tuberculum sellae meningiomas.

Multistaged Surgical Strategy Combined Frontotemporal Approach with Transnasal Approach Using Endscopy: A Case of Radiation-Induced Meningioma

Background: Suprasellar or sphenoid ridge meningioma often invade cavernous sinus, internal carotid artery, and extracranial regions such as the paranasal sinus. Of course the principle for treatment of meningioma is complete resection, but we are rarely able to remove tumors perfectly by the frontotemporal approach alone because of the neurovascular anatomical complexity of this area. We consider that combining a frontotemporal approach with the transnasal approach gives us an expanded capability to treat these tumors.

Trans-sphenoidal Supradiaphragmatic Intradural Approach for Tuberculum Sellae Meningiomas

Purpose: Traditionally, the transcranial approach has been used to remove tuberculum sellae (TS) meningiomas. However, the trans-sphenoidal route has recently been adopted for removal of parasellar tumors. The authors describe use of the trans-sphenoidal supradiaphragmatic intradural approach (TSIA) for removal of presellar and/or suprasellar TS meningiomas.

Trans-sphenoidal Supradiaphragmatic Intradural Approach for Tuberculum Sellae Meningiomas

Purpose: Traditionally, the transcranial approach has been used to remove tuberculum sellae (TS) meningiomas. However, the trans-sphenoidal route has recently been adopted for removal of parasellar tumors. The authors describe use of the trans-sphenoidal supradiaphragmatic intradural approach (TSIA) for removal of presellar and/or suprasellar TS meningiomas. Methods: Six women, aged from 37 to 69 years (average, 59.5 yrs), presented with headaches and visual disturbances. All cases underwent the TSIA via the transnasal trans-septal routes. After removal of tumors, the surgical dural and bony defects were repaired with autologous abdominal fat and silicone plate substitutes. Results: The extents of tumor removal were gross total in 3 patients and subtotal in 3. There was 1 postoperative cerebrospinal fluid leak and 1 aggravation of the visual function. The mean follow-up period was 49.3 months (from 92 to 14 mos). Conclusions: The major advantage of this technique is that it is easily applicable through a minor modification of the standard trans-sphenoidal approach. Although we used this TSIA in a limited number of cases, it can be concluded that TSIA makes it possible to remove TS meningiomas safely in selected cases. However, the transcranial approach is preferred whenever the surgeon aims for complete removal of the tumor.

Suprasellar Meningiomas: Personal Experience in 37 Cases

Introduction: Suprasellar meningiomas arising from dura mater around tuberculum sellae or diaphragma sellae are rare tumors constituting 2 to 6% of all intracranial meningiomas. Tumors of these regions can cause insidious visual loss unilaterally or bilaterally. They are challenging lesions because of their close proximity to major neurovascular structures.

The value of VEP in the diagnosis and post-operative monitoring of meningioma

Meningiomas are the most frequently reported primary intracranial neoplasms. At first they usually cause unilateral visual loss but eventually result in a bilateral loss of vision. Depending upon the size and location of the tumour, the ocular signs and symptoms of meningiomas may include visual field abnormalities, optic atrophy, papilledema, diplopia and proptosis. This case report highlights the value of visual evoked potentials (VEP) in a patient with unexplained bilateral optic atrophy and a progressive loss of vision over 2 years. As a result of a delayed response in the VEP recorded from the right eye, a compressive lesion of the optic nerve was suspected. That prompted the referring ophthalmologist to request a MRI scan which led to the diagnosis of meningioma. Following the subtotal removal of the suprasellar meningioma, the remaining vision in the right eye improved and the latency of the VEP returned to the normal range. However, the VEP from the blind eye (left) did not show any measurable response either pre- or postoperatively. Experience with this patient suggests that early recognition of optic nerve compression is vital to an optimal outcome and the VEP technique, which is much more cost-effective than MRI, is clinically useful for detecting such compressive lesions.

Visual Outcome in Surgically Treated Suprasellar Meningioma

Visual Outcome in Surgically Treated Suprasellar Meningioma

Spinal intradural clear cell meningioma following resection of a suprasellar clear cell meningioma

The authors report on 32-year-old woman with a history of a previously resected suprasellar clear cell meningioma (CCM), who returned to their institution after 3 years suffering from progressively worsening leg and back pain associated with leg weakness and bowel and bladder dysfunction. A magnetic resonance image of the thoracic and lumbar spine demonstrated a homogeneously enhancing intradural mass that filled and expanded the thecal sac. The patient underwent multiple-level laminectomies for resection of the lesion. Results of pathological studies confirmed distant recurrence of a CCM. Since its initial recognition as a rare but aggressive histological variant of meningothelial tumors, the body of literature on CCMs has grown to include more than 40 cases. Nevertheless, the natural history of this neoplastic entity remains ill defined, as are the recommendations for management. Of particular concern is the treatment of patients who have undergone subtotal resection or present with recurrence. To the authors' knowledge, the present case represents the sixth distant recurrence of CCM reported in the literature. The radiographic and histological studies are reviewed along with the current literature on this subtype of meningioma. Recommendations for surveillance and treatment are made.

A Mechanical Theory to Account for Bitemporal Hemianopia From Chiasmal Compression

The association between bitemporal hemianopia and chiasmal compression is well recognized. The majority of chiasmal syndromes are caused by extrinsic compression from pituitary tumors, suprasellar meningiomas, craniopharyngiomas, and aneurysms. However, it is not clear why compressive lesions of the chiasm show a predilection for damage to nasal fibers with bitemporal hemianopia. Few experimental attempts at elucidating these mysteries have been reported and none has provided an adequate explanation. The authors postulate that the susceptibility of nasal fibers to preferential damage is explained by structural collapse theories as applied to crossing and noncrossing cylinders. By constructing a simplified mathematical model, the authors demonstrate that nasal fibers are subject to relatively greater pressures for any given external compressive force acting on the chiasm.

Cerebral aneurysm associated with an intracranial tumour: staged endovascular and surgical treatment in two cases

Two cases are reported in which an anterior communicating artery aneurysm was associated with an intracranial tumour. The tumour was a suprasellar meningioma in one case and an optic chiasm/hypothalamic astrocytoma in the other. In both cases, the aneurysm was successfully embolized using Guglielmi detachable coils. Subsequently craniotomy was performed with complete excision of the meningioma and subtotal removal of the astrocytoma. Endovascular techniques can be employed to make the surgical excision of an intracranial tumour co-existing with an incidental aneurysm safer.

The Transsphenoidal Transtuberculum Sellae Approach for Suprasellar Meningiomas

The transsphenoidal approach is the preferred method for removal of pituitary tumors. Suprasellar tumors may also be approached transsphenoidally in the setting of an expanded sella turcica. Suprasellar tumors that are fibrous and not associated with an expanded sella are generally treated with craniotomy. However, transcranial resection of suprasellar meningiomas carries significant risk to the optic apparatus. The transsphenoidal approach may be modified to provide access for resection of suprasellar meningiomas. A consecutive series of patients with suprasellar meningiomas who underwent a transsphenoidal transtuberculum sellae approach were reviewed retrospectively. From January 2000 to July 2002, six patients underwent the transsphenoidal transtuberculum sellae approach. All patients underwent thorough preoperative and postoperative ophthalmologic and endocrinologic testing. Magnetic resonance imaging of all patients was obtained preoperatively, 6 weeks to 3 months postoperatively, and annually. Two patients presented with visual dysfunction and one had signs of endocrine dysfunction. Tumor diameter ranged from 1.5 to 2.5 cm with a mean diameter of 2.1 cm and all tumors revealed magnetic resonance evidence of chiasmatic compression. Gross total resection was accomplished in four of six (67%) patients and no patient has experienced recurrence. Vision improved in both patients who presented with visual dysfunction and one patient with normal vision preoperatively experienced a mild bitemporal hemianopsia. Vision remained normal or improved in 83%. No patient required pituitary hormone replacement postoperatively and no patient experienced cerebrospinal fluid rhinorrhea. The transsphenoidal transtuberculum sellae approach represents a viable alternative to craniotomy for selected suprasellar meningiomas.

Tuberculum Sellae Meningiomas: Microsurgical Anatomy and Surgical Technique

Despite Cushing's accurate description of the anatomic origin of tuberculum sellae meningiomas, many subsequent authors have included tumors originating from the neighboring sella region in this classification. This has led to difficulty in evaluating the surgical results and consensus for an optimal surgical technique. We think this confusion has arisen from Cushing's description of these tumors under the heading "suprasellar meningiomas," which referred to their distinctive clinical symptoms and not their anatomic origin. We describe the microsurgical anatomy and tumor growth patterns to reemphasize the original classification of Cushing's tuberculum sellae meningiomas. Additionally, we describe our surgical approach, which decreases the risk of injury to anterior visual pathways and anterior cerebral circulation arteries. During a 19-year period, 23 patients with meningiomas arising from the tuberculum and diaphragma sellae underwent craniotomies at New York University Medical Center. The tumor size ranged from 2 to 5 cm. All patients presented with symptoms of visual dysfunction; 15 were asymmetrical. Magnetic resonance imaging with and without gadolinium differentiated these tumors from other suprasellar tumors with a high degree of accuracy. All patients underwent a pterional transsylvian approach. Twenty patients had total tumor removal, and three had subtotal tumor removal. There was one regrowth in the subtotal tumor removal group. Patients were observed for a mean follow-up time of 9.3 years (range, 3.6-18.5 yr). Visual acuity improved in 55%, was unchanged in 26%, and worsened in 19% of patients. Two of the oldest patients died from pulmonary complications, resulting in a mortality rate of 8.7%. We think that tuberculum and diaphragma sellae meningiomas are anatomically indistinguishable and should be termed tuberculum sellae meningioma. A pterional craniotomy with microsurgical dissection of the sylvian fissure allows access to these tumors with minimal neurological and ophthalmological morbidity.

Suprasellar cystic meningioma: unusual presentation and review of the literature

We report on a case of suprasellar cystic meningioma. The magnetic resonance imaging of this tumor resembled that of a craniopharyngioma. The definitive diagnosis of meningioma was made only after histopathological confirmation. We conclude that preoperative studies are often equivocal. The possibility of meningioma should be considered in the diagnosis of any intracranial neoplasms with radiological and surgical evidence of a cystic lesion.

Suprasellar Meningiomas

To the Editor: We read with interest the recent article by Drs. Ciric and Rosenblatt (3) concerning the operative technique used in the surgical excision of suprasellar meningiomas. In our opinion, these authors wrote a clear, step-by-step description of the surgical strategy. Nevertheless, herein we add some observations and ask the authors some questions: The authors presented a series of 24 patients who had undergone surgery between 1971 and 2001. Among these patients, three had meningiomas arising at the level of the anterior clinoid that “also involved the dura of the tuberculum sellae, the diaphragma sellae, or both” (3, p 1372). Why did the authors include these cases in their surgical series? The general consensus is that meningiomas of the clinoid must be distinguished from suprasellar meningiomas because of differences in operative strategy, difficulties encountered, and overall morbidity and mortality (1, 4). Meningiomas of the suprasellar area can be handled safely with the use of a pterional approach. The removal of the orbital rim does not improve a craniotomy cut flush with the roof of the orbit if an adequate extradural resection of the greater and lesser wings of the sphenoid and the opening of the superior orbital fissure have been performed already. We add the extradural removal of the anterior clinoid process if the tumor presents as an extension of the floor of the sella and/or the optic canal, information that is obtained from the MRI scan. In our experience the wide opening of the sylvian fissure with release of cerebrospinal fluid allows to minimize the necessity of brain retraction by means of spatulas, as it appear in the pictures presented through the whole article. We think that the sucker itself can be often used as the only instrument to perform a minimal brain retraction. In the Results, the authors report 7 of 24 patients in whom a subtotal resection of the tumor was achieved and 1 patient in whom partial resection was performed. In such cases, the tumor “straddled (rather than displaced), and in some cases engulfed, the pituitary stalk” (3, p 1377). In our experience, we have found that the main hindrance in performing a radical excision of the tumor is the engulfment of some perforating branches of the anterior communicating artery. The pituitary stalk usually presents its own arachnoidal sheath, which permits a relatively safe microsurgical dissection. Concerning the patient with a “tuberculum clinoid” meningioma infiltrating the optic nerve sheath (3, p 1377), the subtotal resection of the tumor did not result in the regression of a preoperative visual deficit. The same patient showed a “near-complete recovery of vision” (3, p 1377) after radiotherapy focused on the tumor residual. This statement is hard to accept. Radiotherapy in the area of the optic nerve is always a high-risk procedure. Last, we emphasize that the preoperative differential diagnosis between diaphragma sellae meningiomas and nonsecreting pituitary macroadenomas with suprasellar extension may be difficult. This is particularly true in cases of subdiaphragmatic meningiomas—so-called type C meningiomas—according to Kinjo et al. (4). We have collected 42 cases of suprasellar meningiomas from our own surgical series. Among these cases, five patients underwent transsphenoidal surgical exploration because of preoperative misdiagnosis (2). Enrico de Divitiis Giuseppe Mariniello Paolo Cappabianca

Pterional surgery of meningiomas of the tuberculum sellae and planum sphenoidale: surgical results with special consideration of ophthalmological and endocrinological outcomes.

The authors reviewed 47 cases of suprasellar meningiomas with special attention to ophthalmological and endocrinological outcomes. All patients underwent surgery performed via a unilateral pterional approach between January 1983 and January 1998. Ophthalmological and endocrinological examinations were performed before the operation as well as 1 week and 3 months postoperatively. A special scoring system was adopted to quantify the extent of ophthalmological disturbances. Complete tumor resection was possible in all but one patient. There were no fatalities and the rate of visual improvement was 80%. The best prognoses were found in patients younger than 50 years and in patients in whom the duration of symptoms was less than 1 year. Before surgery, tumor-related endocrine disturbances were present in only three women who suffered from secondary hypogonadism; two of these patients recovered after surgery. Postoperatively, no patient needed replacement therapy for pituitary dysfunction. The overall tumor recurrence rate was 2.1% (one of 47 cases). For patients in whom long-term (> 5 years) follow-up data were available, the recurrence rate was 4.2% (one of 24 cases). In this series, complete resection of suprasellar meningiomas was possible through a unilateral pterional craniotomy and was associated with a low morbidity rate and no deaths.

Multiple skull base meningioma: case report

BACKGROUND The incidence of multiple skull base meningiomas varies from 1 to 3% in different series. Skull base meningiomas are rare. The pathogenetic role of low-dose radiation seems to be fairly well established in the oncogenesis of meningiomas. Calvarial location and multiplicity seem to be among the distinctive features of radiation-induced meningiomas. Skull base location is a very rare occurrence, mainly because the path of irradiation does not significantly involve this region. CASE REPORT We describe a rare case of simultaneous occurrence of two skull base meningiomas in a 66-year-old female. This patient underwent low-dose irradiation for tinea capitis when she was 8 years old. The patient complained of nuchal pain, paresthesias in both hands, and progressive weakness on her right side. She was admitted to the hospital in September 1994. An MRI showed two masses, one located at the level of the tuberculum sellae and the other at the foramen magnum. These seemed very likely to be multiple meningiomas. The latter lesion, which was more symptomatic and dangerous, was operated on first. Six months later, elective treatment of the suprasellar meningioma was performed with success. CONCLUSION The actual role of previous head irradiation in the oncogenesis of the present meningiomas remains somewhat unclear. Proper management and judicious use of skull base surgery techniques were key factors in the successful treatment of the patient.

Suprasellar meningiomas--neurological and visual outcome at long-term follow-up in a homogeneous series of patients treated microsurgically.

Most of the previously published surgical series of suprasellar meningiomas have two disadvantages: (1) patients involved were treated within a relatively long time period, making analysis more difficult, (2) radiographic long term follow-up examinations with either CT- or MRI-scans were not performed. Both disadvantages were overcome in our retrospective clinical study, consisting of 50 consecutive patients with suprasellar meningiomas treated between 1982 and 1991. Radiological, ophthalmological, and neurological investigations were performed preoperatively, postoperatively and at long term follow-up (mean: 5.7 years). A radiologically confirmed radical tumour removal could be achieved in 84% of patients. Both, the peri-operative mortality (2%) and serious operative morbidity (6%) were low. However, 12% of patients developed late onset epilepsy. At long term follow-up, visual function was improved in 67%, unchanged in 9% and worsened in 24%. In more than 50% of patients the vision showed recovery over a longer time period than the first 10 days after operation. Radiographic control examinations revealed tumour recurrences in 2 patients (both asymptomatic) and progress of residual tumour in 5 patients (2 symptomatic, 3 asymptomatic). Since introduction of modern neurosurgery, a clear improvement in the surgical treatment of suprasellar meningiomas can be observed. However, the still long delay in diagnosing these tumours correctly prevents a further improvement of the ophthalmological results at long-term follow-up. Due to a relatively high rate of late onset epilepsy, anticonvulsive prophylaxis for 6 months seems to be justified. Regarding present preoperative diagnostic measures, ia-DSA seems only be indicated in patients with CT/MRI-scans, suspicious for tumourous narrowing or invasion of major cerebral arteries. In addition, we recommend radiographic control examinations at regular time intervals to confirm radical tumour removal and to detect the "ideal" point of time for renewed treatment.